Regular readers are aware that I have devoted little attention to the healthcare reform debate in my daily columns. My hesitation to engage directly on this topic stems from the enormous complexity of the issues involved and the massive attention that this topic has received since January 2009. As the debate reaches its critical phase, as Washington’s politicians ready themselves for some definitive closure, and contemplate alternative courses of action, I have decided to share with you some insights that should – but that almost certainly will not – influence the final decisions.
1. All human beings ultimately will die: No one is immortal, whatever the medical care available. So even if a society decided to allocate its entire resources to death prevention, death would still occur. More important, because the marginal cost of death protection increases dramatically as an individual draws near to that occurrence – in the United States on average one-third of an individual’s lifetime medical costs are incurred in the final year of life – there are enormously diminishing returns to life-protection. In this sense, death juries are inevitable. Decisions to cut off or to cut back on life protection are made all the time by patients, as well as by doctors, insurance companies, and families. The United States already expends more of its resources per capita on health care than any other nation on the planet. And the outcome is not spectacular, at least in terms of death prevention, though it is markedly better in terms of the quality of lives that continue to be lived. Almost certainly, it expends more than individuals themselves would outlay in a free market in health care, where they would have to confront directly the cost upon their families of hopelessly trying to extend their lives.
2. Health care is not just a matter of medicine and treatment: The good health of an individual is a function, to a considerable degree, of genetic makeup and of personal lifestyle choices. The genetic quality of individuals in society is influenced by evolutionary factors. In a system where survival of the fittest rules prevail, those who survive tend to be the fittest, and medical interventions tend to be less necessary, at least until the end. In a system where medical interventions are common-place, the average genetic quality of the survivors will be lower, and medical interventions will appear to be more necessary. I stress that this is an observation, and not a policy recommendation. I am not competent to engage in making medical policy recommendations. Unlike many others, I am well aware of my limitations in this regard. Personal lifestyle choices, however, are under the direct control of each individual. Decisions to live well, to avoid obesity, to eat well, to avoid an excessive use of stimulants and depressants, to rest and sleep well, to exercise appropriately, and to avoid high-risk activities in general, are way more important than medicines and treatments in improving the quality and duration of one’s life. Sadly, the more that medicines and treatments are made available, the less personal care an individual will take of his own health. This is a problem of moral hazard that tends to be downplayed in the health care reform debate.
3. Individual freedom is worth protecting: As I have explained in these columns, I place the highest value on individual liberty, defined as the absence of coercion by one individual over another. Whenever I read, in the current health care reform debate, about the desire of some individuals to impose their will on others, I cringe. Unfortunately, I have grown to cringe a great deal over the past 12 months as suggestions for various kinds of federal oversight over health care provisions have poured out from the mouths and pens of frustrated would-be dictators. The rush to regulate is especially worrying in this debate, not because it is more prevalent than elsewhere, but because it affects one-sixth of the United States economy. If the liberal progressives have their way on this issue, Americans will find themselves far less free 10-20 years from now, than they have ever been, including colonial times. Worse still, they will find themselves irreversibly enslaved, because they will have rendered themselves dependent on the federal government, a government that will have translated itself from representative of their wishes to dictatorial about their needs. The liberal progressives are well aware of this irreversible shift, as is President Obama, whose primary goal appears to be to shift the United States economy from laissez-faire capitalism to state capitalism and, ultimately to socialism.
4. The willingness and ability to pay principle is relevant to health care decisions: In most areas of economic activity, Americans prize their free enterprise system. They recognize that individuals will be differentially rewarded in such a system, as a result of genetic advantage, level and quality of education, choice of occupation, hard work, and sheer good luck or misfortune. They are compassionate towards those who do less well, as long as they are striving to improve their lot. They are a lot less sympathetic to the undeserving poor, those who have brought poverty upon themselves, and who are disinclined to make the effort to retrieve their fortunes. Although medicines and treatments are viewed a little differently – few individuals would wish to see those without resources left bereft of interventions - most Americans reject the notion that access to medicine and treatments should be equal across society. Just as in other areas of activity individuals with greater wealth have better access to resources, so it should be with respect to the market in health care. Otherwise, the incentive to do well will be severely diminished, and the society as a whole will be relatively impoverished. This issue is downplayed in the health care reform debate because of considerations of political correctness that tend to foreclose on open discussion.
Well, these are thoughts enough for one day. Others will follow in tomorrow’s column. The thoughts that I offer to you may well not change your judgment on the current debate. Surely they will not change the policy outcomes. But I hope that they may provide a shade of difference to your reflections on this very important policy issue.
Tags: healthcare reform, individual liberty, progressive politics, the limited value of life, willingness to pay principle
February 28, 2010 at 1:44 am |
Some good points in this blog that relates to healthcare. I have yelled and screamed about what I see that’s wrong with healthcare today until I am fatigued and ready to quit. The debates and comments in Washington about reform all focus on cost. Until and unless somebody wises up and looks at why it costs so much, nothing will change. We are paying for medically unnecessary care and it will bankrupt the system that is destined for self-destruction. I look forward to more of your wisdom. Maybe I should start blogging again or just shut up.
Charles Clark, Sr., M.d.
February 28, 2010 at 2:24 am |
All of the above points are very relevant. We are all going to die one day. There is nothing we can do about that fact. We are not immortal.
Some of the arguments put forth on why USA must have this legislation have bordered on the absurd. The economy does a lot better without such government interference.
There are other ways that govt could have provided for those who are less well off, including funding for public hospitals, or maybe even means testing for payment of hospital fees based upon a capacity to pay (but not to the tune of the thousands that happens at the moment).
For example, in Australia our “universal” healthcare is a real joke. We have to pay the money up front for visits to the GP, the specialist, or when getting an x-ray etc. Those are not cheap fees. It is because of govt. interference that we are not allowed to cover ourselves adequately for such services. The so called “scheduled fee” is a joke. Doctors have to pay for their rooms, their staff and their equipment as well as insurance.
The govt. takeover of healthcare should get people angry… it is nothing more than a power grab… an attempt to control lives.
February 28, 2010 at 9:15 pm |
Just to add to Dr. Clarke’s comments which are really very valid, I agree that this is something that needs to be addressed. For example does every woman who is pregnant require an ultrasound? Do women over 35 really require an amniocentisis?
There are lines that can be blurred with regard to the plethora of treatments that are available. The same can be argued about the plethora of tests, but let’s look at the reason for some of those tests… LITIGATION…..
When I was in the USA during July, one thing that disgusted me happened to be the ambulance chasing advertisement that I saw whilst we were in Seattle. This advertisement was produced by an ambulance chaser anxious to start a class action suit against the manufacturers of the various arthritic medications. Now the thing is that even the experiments on Vioxx were done at high level doses which are not normally taken by individuals. In fact the packaging always warns against taking non-prescribed amounts because of the potential injury to one’s system. In the early cases against Merck the juries were less interested in the facts of the presented case and more interested in punishing the drug company. Decisions like that push up the cost of the drugs manufactured by Merck – the money to be paid in compensation has to come from somewhere. It really was debatable that Vioxx was to blame for the death of certain patients – more like the conditions were separate and that there was no link. Certainly at a dosage much higher than prescribed there might be a link but that is the responsibility of the consumer to stick to the correct dose. Anyway, the other medications (and I had been on them for years) do have some risk factors for ulcers, but only if you consume them on an empty stomach. Clearly buyer beware should apply to these cases. If the patients have been warned, then they have to take responsibility for things going wrong when they do not follow directions.
LITIGATION not just against drug companies but against doctors in general needs to be limited to those extreme cases where something was definitely wrong and where it can be proven that negligence was responsible for the condition. It should not be a case of every Tom Dick or Harry litigating in a class action suit. This needs to be contained.
LITIGATION or the threat of LITIGATION causes doctors to go down paths that ends up with higher than necessary expenditure, including the overuse of caesarian operations. Most women do not need them, and quite often they are performed for convenience.
Costs also need to be contained when hospitals are dealing with foreign travellers. Some of the charges for simple things have been outrageous. However, this is something that should be dealt with on the state level, not the federal level. It is the concern of state government.
Another area that needs cleaning out is medicare and medicaid fraud. I do know that in Florida the fraud was rife. There has been sufficient evidence of fraud, especially within the nursing home industry. Let the states deal with the fraud first.
Either way, Federal intervention into the health industry is unwarranted. It is nothing more than a power grab to control even more of peoples’ lives. It is indeed unconstitutional to move in that direction.
March 1, 2010 at 9:24 pm |
When any economic good is artificially priced by the power of force (government), it no longer becomes an economic good and becomes wholly a political good.
Political goods, by definition, are not economic.
If such a political good is priced artificially low, by human action that good will be consumed to exhaustion.
If that political good is turned into a monopoly, by human action that good will decrease in quality and increase in price over time.
The difference between the increase in price of delivery and the forcing of the artificial low selling price politically will result in ever-increasing subsidy drawing against the public treasury.
As these two economic force diverge -lower quality and higher costs with ever increasing subsidy payments – the treasury and the tax payer will be eventually exhausted.
The time differential between the beginning of such a program and its eventual collapse will allow the creation of an ever-increasing number of recipients and an ever-increasing dependency on such a program.
At the point of failure of the program will coincide at the peak of its greatest demand.
Such a confluence of events will be politically destructive to such a nation that dares to suffer this.
March 4, 2010 at 9:15 pm |
@Black flag,
you said:
“If that political good is turned into a monopoly, by human action that good will decrease in quality and increase in price over time.
The difference between the increase in price of delivery and the forcing of the artificial low selling price politically will result in ever-increasing subsidy drawing against the public treasury.
As these two economic force diverge -lower quality and higher costs with ever increasing subsidy payments – the treasury and the tax payer will be eventually exhausted.”
From my Australian experience I totally agree with your comments. However, it is not “ever increasing subsidy payments” but ever increasing co-payments due to the difference between the market based cost of the service and the government schedule fee.
To give you an example: I have been having shoulder pain over a period of months, if not years (long story, but the whole thing has been going on for more than 20 years). My doctor (I pay $60 to visit GP with just over $30 returned to me), ordered a CT scan plus x-ray of the shoulder based upon her supposition that I have bursitis (correct diagnosis). Anyway, the cost of the service was $350 which I had to pay on the spot. When I present this to the Government agency Medicare, I will get back $130. That is less than half of what I have paid!!
There are several reasons for this discrepancy:
. the government scheduled fee is ludicrously low.
. the government fails to recognize one of the services and refuses a pay out on that service;
. the market rate for the service is based upon the rental of the office space, the salary of the employees and of course the demand for the service, none of which is considered by the government in setting the fee.
Since I am old enough to remember the system prior to government interference in the first place, yeah I am angry over these discrepancies. Our private insurance is not allowed to cover the gap, meaning that we pay high fees to the insurance company but get little in return unless we go to hospital. Actually, the whole reason for these very unfair provisions is to cause a single-payer system (government only) but it has not worked that way. From the beginning the Whitlam government wanted to take over the health funds and take their reserves.
Anyway, what you say is so correct based upon my experience here in Australia. The cost to the consumer is increasing all the time.
March 20, 2010 at 11:28 am |
Barack Obama’s book, “The Audacity of Hope,” has a appealing title. It has an idea of bravery mixed with confidence. There is nothing Pollyanna regarding it. I may well not support every part he says, but he’s our president, as well as for me, he creates trust. That may do more for any nation than any number of backroom deals. Hope gives us energy, and energy sustains us through trying times. Boy, we’ve had them. I’m from West Texas, and I did not vote for Bush. When McCain ran against Obama, I used to be a citizen of Arizona, but I gave audacious hope a chance. The fight for progress and laying the foundations of prosperity is not over. I have come across the quips of those that don’t believe Obama is capable of doing it. But step back a moment. Would anyone have all of us fail simply to tarnish the star of an incumbent for whom they didn’t vote? Keeping our priorities straight, let’s work together with our president and build our future.